INTRODUCTORY LECTURE / DELIVERED IN THE CASTLETON MEDICAL COLLEGE AT THE OPENING OF THE wim si§»e BY MIDDLETON GOLDSMITH, M. D. Professor of the Principles and Practice of Surgery. DEMOCRAT PRINT. WHITEHALL, N. Y. ^^/BRA^i 1846. Castleton Medical College, Aca. 16, 1846. Prof. M. Goldsmith: Sir:—The Class of the Castleton Medical College, deeply im- pressed with the worth of your Address, introductory to the present Lecture Term of this Institution, hereby through their Committee, most respectfully request a copy for publication. Very Respectfully Yours. W. T. GALLOWAY, N. Y. C. B. MALTBIE, Conn. A. LEONARD, Penn. J. W. CONDICT, N. J. B. F. ROLFE, Vt. J. A. ALLEN, Jr., Mich. S. SANBORN, N. H. J. FERGUSSON, Va. J. BELTON, Miss. T. W. JONES, Ga. R. T. HAYS, O. C. H. BLACK, S. C. To Messrs. Rolfe, Allen, Maltbieand others : Gentlemen:—1 have received your note requesting, in behalf of the Class, a copy of my Introductory Lecture, for publication. A copy of it is at your disposal. Please accept my acknowledgement of the very courteous terms of your communication. 1 am, with great respect, yours, dec. M. GOLDSMITH. Cnstleton, August 17, 1846. ADDRESS, Gentlemen ; The Corporation and the Faculty of the Castleton Medical College, bid me welcome you within these halls, This is a cheerful duty, for it is but the beginning of those ties which, pleasant in themselves, we trust will be remembered through our future lives. The occasion which brings us together, naturally suggests certain sub- jects of thought, prominent amongst which, stand the nature of and the duties pertaining to that station, which you intend preparing yourselves to enter. Doubtless most of you have considered this matter in some of its features already; with such, a renewed contemplation may serve to confirm their present convictions, whilst to others the presentation of the subject may offer thoughts at least not clearly entertained before. The present era in medicine, and the momentous questions embraced, force themselves so strongly upon our attention, that we must give to them a considerate and extended deliberation. I shall, therefore, gentlemen, after stating as fairly and as candidly as I can the advantages and disadvantages offered by medicine as a pro- fession, its duties and responsibilities, devote the remainder of my re- marks to the subject of the proposed reforms in teaching medicine, and licensing the practice. You often hear it said by physicians, from the common disposition of each to magnify his hardships — that there is no profession involving so much sacrifice of comfort, so much hard labor, and such anxious respon- sibility without remuneration, as does their own. The declaration is in a degree correct; for it is a matter of sober, earnest truth, that except the ministry of the sacred desk, there is no calling amongst men in. which there are, day and night, such incessant demands upon his time, his sympathies and his charity; and perhaps no man has so often and so distinctly brought home to him a sense of anxious, solicitous responsi- bility. The rewards of practice are usually adequate to the proper sustenance of the practitioner, presenting in this respect, at least the average emol- uments of the learned professions: for whilst in law. for instance, there 6 may be more frequent examples of great success, in medicine, employ- ment (except in large cities) is more equally distributed. Pauperism is much less seldom known in medicine than in any other walk in life, and the instances are rare in which moderate industry, attention to business, and economical habits do not enable the practitioner in physic, to educate his children well, and accumulate some little property. If medicine demands the sacrifice of comfort, and involves the constant use of his sympathy, the physician can not but feel that every such exer- cise of his calling, carries to the afflicted a much larger share than he loses, and his sympathies are repaid in kindly feeling a hundred fold. I believe it to be, however, the candid experience of every practitioner, that the responsibility of his practice is the hardest to be borne. It is an evil which presses upon him in every case endangering life or limb; it is a feeling which meets him at every step, which haunts him in his wak- ing hours, and in his dreams. No man can tell as he, how solemn, how terrible, in the house of death and mourning, comes the question—hast thou done thy duty ? True, he may say—God knows I have done the best that I knew how. Aye, but hast thou informed thyself well of all that might have been done? It is this, gentlemen, which in all others than the fool or the brute makes the responsibility so hard to endure. It is this consideration beyond all others which should impress upon you the absolute and essential necessity of earnest application to study, for when the practitioner can feel that he has fully informed himself, the fault, if there be any, rests not with him, but in the imperfection of the science and the art. Take these considerations home to yourselves—not as matters of general application, but as interesting each one of you specifically. There is another point of view in which the profession must be looked at. I refer to the career it opens for ambition to run. Medicine presents less opportunity than any other profession, for the acquisition of a brilliant and early reputation. The physician's excel- lencies are of the useful, not the splendid sort. His orovince is to enlist the love rather than the admiration of his fellow-citizens. Every effort of skill is directed to individuals, not to communities. The settlement of each rule of treatment interests persons, not the public ; and hence the acquisition of a reputation comes rather of accumulated instances of the application of his skill, than of the enunciation and enforcing of a great and encompassing principle. Every question of law, of morals, of pub- lic policy, touches the welfare of whole communities, and the discussion of such questions is usually before large assemblages of people, or if written, addresses itself to the public at large. The etiquette of medicine confines the practitioner within the narrow limits of personal intercourse. 7 whilst the lawyer, divine and statesman have the freedom of many aven- ues to the public attention. The physician appeals to the world through representatives, his works and his friends,—the others in their own proper person. Such, gentlemen, is in some degree, the nature of the profession in which you would enter. Learn to estimate aright its solemn responsi- bilities, its cares, its sphere of humble usefulness, or disinterested and noble, ambition. The limits of an ordinary Address will not allow me a more extended consideration of this branch of my subject. ' I shall proceed, therefore, to consider the proposed reforms in teaching and licensing the practice of med- icine. I am the more inclined to enter upon this subject that it is one which, since 1841, has claimed my earnest attention, and one in which, I think I may safely say—and can refer to my written publications in the journals of 1842, and my personal and written communications to eminent men throughout the State of New-York — that I have taken an early and active part. The resolution offered by Dr. Bartles, at the late sitting of the National Medical Convention, embody the views which I then set forth and advocated, so that you will perceive that these are no new views of mine, but opinions held for several years, and confirmed by sub- sequent reflection. The first objection to the present system is, that teaching in its practi- cal working, is a monopoly. It is vested in a few chartered schools. It may be urged that any man may lecture and teach medicine, but the fact that chartered schools aretheonly sources of amedical diploma (which is in some States the license to practice) renders this privilege a nullity, since students having the diploma in mind, prefer to attend at once, wherein any case they must attend if they would graduate. The rule of all col- leges that the candidate for graduation must have attended two full cour- ses of lectures, one of which must have i been in the school where he would graduate, makes it obligatory upon the student to attend the teaching of the schools whether he prefers it to private instruction or not. Thus the Physician or Surgeon in private life, ever so well qualified to lecture must leave his talents unemployed, at least po far as systematic courses are concerned. This is a great evil. It prevents that free compe- tition amongst men, which where no greatpublic good is to be gained by the prevention, ought never to be interrupted, for its interruption is im- politic and unjust—unjust in itself, and impolitic that in preventing this competition, it prevents the development of an additional portion of tal- ent, and in a measure, retards the advance of the science and the art, in the country where the policy holds. At least we are warranted in hold- ing this opinion, by comparing the condition of medicine amongst those 8 nations where all may teach, with that of those where the business is confined to the few. I would not be understood as advocating the multiplication of medical schools as now constituted. They are too numerous already, but I would have the profession of teaching whether private or public, thrown open to all who choose to enter upon it, demanding of them however the most effi- cient instruction, as demonstrated by a rigid examination of the pupils. There is another objection 10 the alliance of teaching and licensing; it is that the teacher is hardly an impartial or competent judge of his pu- pil's proficiency in the branch he teaches, for a judgment upon the stu- dent's knowledge, involves a verdict upon his own. The professor's vote is based upon the candidate's proficiency in the branch of medicine as taught by him rather than in the branch itself as generally received. Now as the diploma purports to be the evidence of the graduate's competency to practice—the Professors' signatures set forth that the graduate is fully acquainted with each of their departments of the healing art, according to the received rules, principles of opinions of the profession, or else the parchment sets forth nothing but an attendance upon lectures, and beyond that is an absurdity. Since then every declaration of the candidate's ability involves a judgment on the teacher's knowledge pronounced by him- self, it is clear that the adjudication of the question cannot be impartial in its present hands. If all the departments of medicine were governed by settled rules, or in other words were every branch of the science de- monstrative, unencumbered with theories or speculation, inasmuch as there then could be no difference of opinion, the evil would not exist. But every day's observation shows that the evil is a real one, and that it de- mands a remedy. The experience of most physicians, at least of those who think for themselves,—is, that they have sometimes learned things in the schools which they have unlearned in practice. I wish here to state that in discussing this question, my remarks apply to the giving the degree of doctor in medicine, where, according to leg- islative enactments, the degree is a legal license to practice. For when the diploma does not confer this right, it is but an academical honor, giv- ing nothing to the graduate but a title, and deriving its value from the character of the schopl from which it emanates, carrying great weight when the requisitions are of the highest order, or utterly worthless when conferred without consideration. Viewing the matter in this light, we perceive that when the diploma of a medical school confers upon its re- cipient special rights and privileges it must have obtained its power so to do from legislatures. It is not reasonable to suppose that the common- wealth would have delegated this power to any body or bodies of men unless with the implied or expressed stipulation, that that power should 9 be exercised for the public good. Legislatures are not usually competent judges of medical matters, and acting on this, they delegate the adjudi- cation of them to corporate bodies, which being composed of physicians, will see to it that none but those qualified to practice, shall be allowed to take charge of the public health. The necessity for this restraint grows out of the importance of the interests involved, and the universally ac- knowledged fact that the mass of people are less able to judge of skill in medicine, than of skill in any other profession. You will see from this, gentlemen, what a high and onerous responsi- bility rests upon those whose diploma confers the right to practice, and how necessary it is that such guards and restrictions should be thrown around the licensing power as will ensure its faithful exercise. I proceed then, to remark that another objection to the present system is, that influences are constantly at work to make the acquisition of the degree more easy than it should be. To assert that there is a great deal of competition amongst all schools (medical, legal and theological) for public patronage, that the fees for graduation in large schools amount to a considerable sum, that each unsuccessful candidate becomes an enemy, whilst each graduate grows into an active friend — is to state nothing more than is already known; and to assume thai these, to say nothing of the pain that every kind-hearted man mnst feel in inflicting upon a student the deep mortification of a rejection, can have no influ- ence upon the graduating power, is tu assert that the members of learned colleges are not to be acted upon, as are all other classes of men. If we add to this the fact that all schools (except some two or three which have delegates appointed by the State Medical Society, for the purpose of attending the examinations,.as in the Castleton Medical College,) con- duct the final examinations in private, we can not but see how easily the exercise of a momentous duty may be made to serve private ends rather than the public good. Such, gentlemen, are the objections to the continuance of the, union, where it exists, of teaching medicine and licensing the practice; for- it cannot but be seen that young men are often hurried into practice, partly by their own necessities it is true, before they have received that thor- ough training which fits them for the care of life and health. The fault of this, under the present system, belongs in my judgment rather to their private than to their public instruction, as far as it is owing to their pre- ceptors. Three years of study, including two courses of lectures are, by the common law of schools, the pre-requisites for graduation. How often is the first portion of the student's knowledge obtained from text- books years out of date; the best in their time, 'tis true, but containing much that is now'fabandoned.—opinions and rules of practice are being B " 10 supplanted constantly by others that are better, we trust; at all events, many new and also valuable facts are daily added to the stock of knowl- edge. So that he who draws his information from authors who wrote twenty years ago, whilst he gains from them much that is valuable, has at the same time acquired opinions which, when he comes to lectures, he must unlearn, and must then learn much that he never heard of before. Besides, it is often the case that the pupil is set down in the preceptors of- fice, his time is in a measure taken up in the business of an apprentice, and in lieu of examinations and explanations of the difficulties that he meets with, the preceptorship is filled up by the simple direction to read this or that author first, and another next. 'Tis true there are instances in which the private preceptor devotes much time and attention to the advance of his pupil; and such students are at once known when they come here; but the evil I mention is a prevalent one, and every one who has had much experience in teaching has found it so. It is not my pur- pose to enlarge on this subject, but simply to point out< the evil, and, in the proper place to suggest, the remedy. It will be seen, gentlemen, from what I have already said, that certain evils do exist, and the questions now come, what is the right remedy 1 In whom does the remedy lie ? The right remedy is, the vesting, by legislative enactment, the licens- ing power in a separate board of examiners who shall not be teachers, providing for the selection of proper and efficient persons for holding the office of public examiners, and guarding the power with proper restric- tions. What is it reasonable to suppose would be the effect of Ihe institution of such a body in the manner mentioned, upon the practice and the pro- fession ? Let us suppose its existence in this State for instance. What effect would it have upon yourselves, gentlemen? If I mistake not, you would reason thus, at least such of you as intend practising within the State: U,I must apply myself most diligently to study, for I have two ordeals to pass, the green room for my diploma, the central board of examiners for my license. The faculty are my friends, 'tis true, and they feel per- sonally interested in my success. I can trust to that to help me somewhat to the degree. But the members of the central board do not know me. nor I them. They have no personal interest in me or in my success. Their examinations are open to public inspection. The eyes of the whole pub- lic and profession are upon them and their doings. They cannot license me if they would, unless I am fully and fitly prepared. Therefore I .must trust to myself, and not to them." What would be the effect upon us? I for one should reason thus:— 11 •' The excellence of my teaching is now plainly at stake, not as regard* fluency of diction, elegance of style, or agreeable discourse ; but as re- gards the sterling qualities of the teacher's skill—my ability to impart just that kind of knowledge which will prepare the student for the practical duties of his profession, for the result of my endeavors is to be judged of by competent and impartial men." The practical working of this would be, that every preceptor would extend to his pupil the hearty hand of fellowship, saying, "come and let us work together." I trust that this spirit already animates your preceptors. But the proposed arrangement would doubtless serve to heighten the feeling which now exists, and by stimulating the teacher and the taught, increase the capacity of both. Besides, the establishment of this criterion of merit, would create a tri- bunal of comparison between schools, adding a mest honorable rivalry to the stimuli already existing. It would have its effect upon the private preceptor, for those who would then have the eclat of teaching, would be forced to supply themselves with the proper appliances, and devote time and care to the studies of their pupils. Who can doubt that this is a consummation most devoutly to be wished for. That such would be the working of the system is not merely a plausible speculation, but a con- clusion to which we are warranted in coming, by observing the effect of the system where it is already in operation. A moment's reflection will show that the securing of this effect, must depend upon the right quality of the board. And this leads to a consid- eration of the way in which the organization should be reached, and the rules to which it should be subjected. The chief difficulty, and it is a great one, which meets us here, is the selection of the proper incumbents of the office of examiners; for unless the appointments are made accord- ing to the spirit of the system, no good can result from it. The appoint- ments cannot be vested in gubernatorial or legislative officers, for such besides their incompetency in the premises, are notoriously open to im- proper influences. It seems to me that there is the best prospect of reaching the object, by reposing the power of selecting such a board, in a proper represenm- tiVe body of the profession of the State. Such an arrangement, inasmuch as it leaves the matter in the hands of those most interested, will secure the most faithful exercise of the power. If a body thus elected were paid a liberal salary by the State (the fees for graduation going into the State Treasury) if the examinations were public, or questions and an- swers recorded, there is every reason to suppose that it would serve the intended purpose. There is nothing novel in this measure, for the like policy is practised in regard to theological and law schools. Candidate for the ministry are, in most denominations, required to pass the examin- 12 ation of a board of clergymen, and a certain number of judges appointed to enquire into the qualifications of those who practise law. If this guard is held to be necessary in Divinity and Law, how much more is it neces- sary in Medicine, where the public are so much less qualified to judge of the practitioners skill? The public safety, and the character of the pro- fession demand that the requisitions of the license should be greater and more strict. It is not within the province of the schools,—the common- wealth and the profession must apply the remedy. It is not possible 1 know for them to prevent the ignorant from employing quacks or irregu- lar practitioners, but they have it in their power to require that every one who assumes the physician's duties shall be acquainted with the ele- ments of medicine, the construction and laws of the human economy, the signs and effects of disease, the composition and effects of drugs, as well as the management of surgical operations. There could be no objection raised to this proposition, if urged upon a legislature, for the physicians of all systems, from the educated to the Thompsonian, pretend that their rules of practice are based upon the known laws and structures of health and disease and the effect of drugs. That quackery exists in its many forms is owing to the want of capa- city and success in the accredited praciitioner. though something is due to the credulity of ignorance. The public is governed in a great meas- ure in the bestowal of its confidence by the success of the art; and in the measure that medicine, based upon the accumulated and enlightened experience of centuries, is better than the dreamings of an enthusiast or the pretensions of a charlatan, its qualified practitioners will secure the confidence of the public. Provided the divorce of teaching and licensing should ever be accom- plished, a question will arise as to the pre-requisites for the examination before the licensing power,—shouid there he a specific period and method allotted to the pursuit of the study, or should there be no other question than that of competency? If a specific period be required, what is to be the evidence that the applicant has been engaged in study for the allotted time? The certifi- cate system, now universally prevailing, is liable to abuse, for the gen* uineness of the certificate purporting to come from a preceptor, rests after all upon the reliability of the person presenting it. From the very nature of the case, it is impossible for a faculty, a board of trustees or examiner?:, where there are a number of such certificates before them, coming from all parts of 1 he country, to learn whether the names ap- pended to them be genuine, or whether the preceptor is a regular practi- tioner or not. It is true and gratifying that such is the honorable feeling amongst medical students, that such abuses arc seldom practised, but 13 the very possibility of their occurrence is an objection to the system itself. Hence in the proposed arrangement we would be forced to have the certificate properly attested, or allow all who are competent, to practise without regard to their term of study. In the latter arrangement there is little doubt but that at least three years would of necessity be employ- ed, although not made requisite by the law. This is a matter, however, of secondary importance, belonging perhaps to the licensing power itself. It is not my purpose to enter upon details, but rather to enforce the great principle embraced in the proposed measures. This scheme of reform has doubtless been both advanced and opposed as n.na7iti-school measure, but in my judgment it cannot be regarded as at war with existing institutions. As far as the charters of Medical Col- leges are concerned, it is a dead letter, for it does not propose to rob them of the power of conferring degrees or to lessen their real value, for in many of the States in the Union no license is required for the practice, so that in point of fact the degree now is but an academical honor—and even where the diploma of a Medical School, when registered, confers the license, the power is not thereby ceded forever from the State to en- act such laws as its wisdom may dictate for the regulation of its medi- cal police. This principle has been clearly declared in the late enact- ments of the legislature of New York. For anterior to the year 1844. the registration of a diploma (conferred by a College within the State) in the Clerk's Office of the county, conferred the right of practice, but since that period the law has been done away with, for all are now al- lowed to practice, and collect their fees by suits at law. Some charters are irrevocable, but to assume that the government has no power to de- clare by legal enactment who shall or who shall not practice.—is to de- clare a principle which would not be listened to by any legislative body and could not be tolerated by any people. The degree of any College is but an evidence of the education of its holder, and as such only has it value: as such it will always be esteemed and sought after. The institution of a central board so far from injuring the classes attending Colleges, would serve rather to increase the num- ber, because it would oblige all those now without the profession—I mean Botanic physicians and the like—to so prepare themselves, whatever their future practice may be. so as to be able to meet the requisitions of the central board. Students during the term of their private pupilage, would seek the offices of those who best prepare themselves for the work of instruction; a race of Anatomists. Surgeons. Practitioners and Chemists, would be springing up in our larger towns, who would thus be training themselves for the business of teaching; these as they became prominent, would be 14 called into Colleges, thus giving 1o the Colleges a broader field for the selection of competent incumbents for their chairs. Such gentlemen are some of the effects which we are warranted in asserting will follow the adoption of the proposed measures of reform in teaching and licensing medicine. I say that we are warranted in assert- ing this, because the measure has already been tried in its substantial parts in other countries, and wherever tried has been followed by these results—and what it has worked out in other places it is but reasonable to suppose that it will work out here. This is substantially the measure of reform which I set forth and ad- vocated in 1S12, and at proper times have advocated ever since. I urged it when out of a school, and I urge it now when in a school, for I do not regard it as interesting the Medical Colleges in any degree as it does the medical public. I urge it because in my judgment, it would not only ele- vate the standard of medical education, but would keep the practice in a great measure within their own hands — and thus increase the usefulness and the rewards of the profession. It is not to be disguised that there is in a part of the profession a spirit of hostility to existing institutions. They have striven to throw the de- ficiencies of medical education, where such exists, upon the schools, for- getting that the more important fact of the novitiate's education is in his private pupilage. They strive to make it appear that degrees are inconsiderately given, forgetting or not being aware of the fact ihat in all Colleges, rejections are much more frequent than can be publicly known, that it is the kindly policy of professors to dissuade the student from offering himself, where they are aware of his want of qualification rather than subject him to the mortification of a rejection. The fact too cannot be denied that whilst there are numbers of emi- nent men in private life who are earnestly engaged in adding to the store of medical facts, the great body of the additions to science have been contributed by the occupants of professorships in Medical Schools. Who have contributed to surgery as Mott, Warren, Stevens or Beaton?— Who to practical medicine as Eberle, Jackson. Bartleti, ^'inith or Sweet- ser? Who to our indigenous materia medica like Tully, Perkins or Ben- ton? Who to midwifery like Devvees and Francis, not to rhention many others whose whole careers are marked by the accumulation of exper- ience. There, has been no other guard (as far as institutions are concerned) to the profession, than the schools. They have by their teacliin